Arthroscopic Bursal-Sided Transtendon Double-Pulley Repair of Intratendinous Rotator Cuff Tears

Abstract

Intratendinous tears of the rotator cuff, a specific pattern of partial-thickness rotator cuff tears, are relatively common. Depending on the type of partial-thickness tear, surgeons may opt for debridement, acromioplasty, or repair (either conversion repair or in situ repair). However, there are only a few articles that focus specifically on the arthroscopic repair of intratendinous rotator cuff tears. Arthroscopic bursal-sided, transtendon, double-pulley repair is a practical surgical technique that aims to preserve the original structural integrity of the tendon. This method compresses the bursal-sided layer onto the bone, while minimizing the risk of tension mismatch between the articular and bursa sides. The procedure is relatively simple, as it does not require sutures to pass through the rotator cuff tendon itself. Additionally, it facilitates early rehabilitation and reduces the risk of postoperative stiffness.

Intratendinous tears (ITTs) of the rotator cuff are a relatively common subtype of partial-thickness rotator cuff tears (PTRCTs).¹ In a study of 268 cadavers, the prevalence of ITTs (7.5%)² was even higher than that total of bursal-sided (2.6%) and articular-sided (3.7%) tears. PTRCTs may progress to full-thickness tears (FTRCTs). The patients usually underwent arthroscopic repair when conservative treatment failed. Even for cases in which the intratendinous tear encompassed more than half of the tendon thickness, arthroscopic repair can restore good structural integrity.³

According to the different thickness of PTRCTs, arthroscopic treatments include debridement, acromioplasty, and repair.⁴ Regarding ITTs (Fig 1), surgeons must make a decision about whether and how to repair them, considering whether they are PTRCTs or FTRCTs, and whether these can be remedied by in situ transtendinous repair. In this article, we present an arthroscopic bursal-sided, transtendon, double-pulley repair technique designed to maximize preservation of the tendon’s original structural integrity.

Fig. 1.

(A) Overview diagram of intratendinous tear of rotator cuff. (B) Sectional view of intratendinous tear of rotator cuff, with the bursal and articular sides intact. Black arrow denotes intratendinous tear of rotator cuff. ISP, infraspinatus; SSP, supraspinatus; SSC, subscapularis.

Surgical Technique

Preparation

We prefer to perform the procedure with the patient in the lateral decubitus position (Video 1). A posterolateral viewing portal and an anterior working portal are established to conduct diagnostic arthroscopy with a 30° arthroscope. This allows for evaluation of the glenohumeral joint and confirmation of the intact articular side of the rotator cuff.

Diagnosis and Evaluation

The arthroscope is advanced into the subacromial space, and an anterolateral portal is created for operation. A subacromial decompression or acromioplasty is performed if subacromial impingement is observed. On the basis of the location of the rotator cuff injury, a lateral viewing portal is created at approximately the “50-yard line”—a point midway along the lateral border of the acromion. The arthroscope is then transferred to this viewing portal, and a limited bursectomy is performed for improved visibility.

A hooked probe is used to palpate the abnormal bursal side rotator cuff to assess frailty, depression, softening, or erosion of the tendon. These subtle changes may indicate bursa-sided or ITTs, even in the absence of a clearly visible defect. If necessary, the saline can be injected with an 18-gauge spinal needle inserting into the center of the suspected rotator cuff lesion, and expansion within the rotator cuff tendon without any resistance can be watched, which called ‘‘saline test’’ can be performed to ensure the existence of an ITT. Finally, a probe is inserted into the rotator cuff to thoroughly evaluate the tear morphology and the extent of delamination within the tendon.

Medial Row Anchor Insertion

An 18-gauge spinal needle is inserted via a percutaneous approach to the anterior edge of the acromion to determine the optimal trajectory for medial-row anchor placement. After confirming the trajectory, a small incision is made, and a cannula (Crystal Cannula; 5.75 mm ID, Arthrex, Naples, FL) is inserted into the portal. A punch (4.5 mm D, Arthrex) is inserted through the bursal side of the rotator cuff at the anterior margin of the ITT, ∼10 mm medial to the lateral margin of the rotator cuff. Palpating the footprint with the punch, a pilot hole is then created at this location. While the assistant stabilizes the cannula, the punch is removed, and a 4.5-mm HEALIX ADVANCE Br suture anchor (DePuy Synthes, Warsaw, IN), loaded with 1 blue suture and 1 purple suture, is inserted. Accurate punch positioning is critical, as inserting the anchor into an unmarked pilot hole can be difficult. The same technique is repeated to place the posteromedial anchor at the posterior margin of the ITT (see Fig 2).

Fig. 2.

(A) Arthroscopic image of right shoulder (with patient in lateral decubitus position), as viewed through subacromial lateral portal, showing the insertion of the anteromedial anchor. The assistant holds the cannula steady while pulling out the punch, until the anchor is inserted. (B) Diagram of medial row anchors bursal-sided, transtendon insertion. The anteromedial anchor is inserted on the anterior margin of intratendinous tear, ∼10 mm medial to the lateral margin of the rotator cuff and the the posteromedial anchor on the posterior margin of intratendinous tear. ISP, infraspinatus; ISP, infraspinatus; SSP, supraspinatus.

Following medial anchor placement, microfracture of the footprint between the bursal-side and articular-side layers is performed using a perforating awl (Arthrex) before suturing the rotator cuff. The precise location is determined by palpating the bone with a perforating awl (Fig 3).

Fig. 3.

(A) Arthroscopic image of right shoulder, viewed through subacromial lateral portal, showing the process of microfracture. Microfracture of footprint between the bursal-sided layer and the articular-sided layer is performed using a perforating awl (red arrow). Microfractures are performed every 3–4 mm of distance to a depth of 4 mm. (B) Diagram of microfracture. ISP, infraspinatus; ISP, infraspinatus; SSP, supraspinatus.

Suture Management

One suture from each medial row anchor is removed, leaving 1 blue suture from the anteromedial anchor and 1 purple suture from posteromedial anchor. The double-pulley technique is then performed using the remaining suture strands. Each suture strand from the anteromedial and posteromedial anchor is retrieved through the anterolateral portal to approximately half their length. These 2 strands are tied extracorporeally. The remaining blue and purple strands are pulled simultaneously, allowing the knot to be drawn down through the cannula to the rotator cuff and guiding the knot near the anterior medial row anchor. Finally, the remaining blue and purple strands are retrieved through the anterolateral portal, and a static knot is tied as posteriorly as possible using a knot pusher (Fig 4).

Fig. 4.

(A) Arthroscopic image of right shoulder, viewed through subacromial lateral portal, showing that the sutures are knotted in a standard fashion of a double-pulley technique. (B) Diagram of the sutures knotted. ISP, infraspinatus; ISP, infraspinatus; SSP, supraspinatus.

Lateral Row Anchor Insertion

The lateral row repair is performed in a standard fashion using a double-row suture bridge technique. The sutures with the same color as a group are retrieved extracorporeally and compressed onto the greater tuberosity by a lateral row anchor (4.75-mm PEEK SwiveLock anchor; Arthrex).

An anterolateral anchor and a posterolateral anchor are placed (Fig 5). With both lateral anchors in place, the maximum range of the bursal layer is effectively compressed onto the articular layer.

Fig. 5.

(A) Arthroscopic image of right shoulder, as viewed through subacromial lateral portal. The lateral row repair is completed in a standard fashion of a double-row technique, retrieving the sutures from each medial row anchor, loading each lateral row anchor, and tensioning each limb independently to remove any slack of tendon. The lateral anchors are placed, and the tails of the sutures are cut. The completed bursal-sided transtendon double-pulley repair of intratendinous rotator cuff tear can be seen here. (B) Diagram of the last view. ISP, infraspinatus; ISP, infraspinatus; SSP, supraspinatus.

Discussion

For PRCTs and FTRCTs, the standard technique (full-thickness repair) remains the preferred approach for many surgeons, as it simplifies both tear assessment and surgical repair. However, this technique requires permanent excision of the native tendon tissue.⁵ The surgeons prefer in situ transtendinous repair for PRCTs involving articular-sided tears in order to preserve the native tendon–bone tissue.6, 7, 8 The benefits and underlying mechanisms of this approach have been demonstrated in studies by Mihata et al.⁹ and Dey Hazra et al.¹⁰

Few articles have dealt specifically with the repair of ITTs. ITTs are usually repaired by conversion to bursal-sided tears. Murat et al. demonstrated successful clinical outcomes with a minimum 10-year follow-up.¹¹ Furthermore, Park et al. reported that transtendon suture bridge repair, different from our technique, and yields good outcomes.¹²

A potential drawback of in situ repair is the differential tension that may develop between the articular and bursal sides of the tendon, possibly leading to postoperative pain and stiffness.^13,14 Starting on the second postoperative day, patients began passive anteflexion exercises 5 times daily while in bed, continuing for the first 6 weeks. No increase in pain or stiffness was observed during this period.

Previous literature has reported that the healing rate of rotator cuff repair was similar, regardless of whether bone marrow stimulation was performed or not.¹⁵ Animal experiments have confirmed the beneficial effect of microfracture in promoting rotator cuff healing.¹⁶ This technique involved using a perforating awl to precisely place microfractures in the footprint between the bursal-side and articular-side layers using a perforating awl. Mesenchymal signaling cells that are released from the humeral head can be retained intratendon, as the “crimson duvet” technique promotes the healing of the delamination rotator cuff.^17,18

The combination of the double-pulley and double-row repair is a widely used treatment for rotator cuff tears. It can eliminate the intratendon cavity in this technique. The two double-loop sutures and double-row repair can provide the maximum compression of the bursal-side on the articular-side and greater tuberosity bone bed, improve tendon healing.¹⁹ As a result, this significantly simplifies the complexity of the operation.

Our bursal-sided transtendon technique is similar to previously described in situ repair methods; however, it eliminates the need to pass sutures through the rotator cuff tendon. Compared with the tear completion, it maximized the preservation of the integrity of the native rotator cuff tissue. By employing the double-pulley and double-row techniques, the bursal layer is effectively compressed onto the articular layer and the greater tuberosity. This construct not only enhances tendon-to-bone healing, but also facilitates early rehabilitation exercises. The surgical technique is described in Table 1 (advantages and disadvantages) and Table 2 (pearls and pitfalls).

Table 1.

Advantages and Disadvantages

Advantages The procedure of the technique is simple. The technique is reproducible and suitable for less experienced surgeons. It is unnecessary to pass the sutures through the rotator cuff. It maximizes preservation of the integrity of the rotator cuff tissue. Native tendon tension is maintained. Maximally compress the bursal layer of the rotator cuff onto the articular layer. Early rehabilitation exercise is feasible.

Disadvantages Finding the anchor’s pilot hole can be challenging for trainees. The depth of the anchor cannot be viewed directly. Microfractures may damage the insertion of the rotator cuff. The pathological tissue between the bursal layer and articular layer cannot be removed.

Table 2.

Surgical Pearls and Pitfalls

Anchor Implantation Considerations 1.Evaluate the tear morphology and the extent of delamination within the tendon using a probe thoroughly to make sure the anterior and posterior location of medial row anchors. 2.Palpate the footprint with the punch before the pilot holes are created to ensure that the medial row anchors are placed at the footprint and not in the articular cartilage. 3.While the punch is removed, the assistant stabilizes the cannula as a mark to insert the medial row anchors easily. 4.Without visualizing the depth of the medial row anchors, they should be screwed relatively deeper, not shallower. Microfracture Consideration Palpate the footprint between the bursal-side and articular-side layers with a perforating awl before microfracture is performed, avoiding destroying the integrity of the rotator cuff tissue.

Disclosures

The authors (W.D., S.D., Y.X., Z.S., M.B., J.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

The patient is positioned in the lateral decubitus position. Using a 30° arthroscope, the surgeon begins the procedure by evaluating the glenohumeral joint and the articular side of the rotator cuff. Then the surgeon transfers the arthroscope to the subacromial space. After subacromial decompression or acromioplasty, the “bubble sign” is performed to confirm intratendinous rotator cuff tear. The tear morphology and delamination range of the rotator cuff will be thoroughly evaluated with the probe. Then a portal besides the anterior edge of the acromion is established to insert the medial row anchors. The punch is inserted to open a pilot hole through the bursal-sided rotator cuff, on the anterior margin of tear, ∼ 10 mm medial to the lateral margin of the rotator cuff. The assistant holds the cannula steady while pulling out the punch, until the anchor is inserted. The posteromedial anchor is inserted in the same way, on the posterior margin of tear. Pull away a suture from each anchor. Microfracture of footprint between the bursal-sided layer and the articular-sided layer is performed by palpating the bone substance with the perforating awl. Then the sutures are knotted by the technique of double-pulley. The lateral row repair is completed in standard fashion of a double-row technique, retrieving the sutures from each medial row anchor, loading each lateral row anchor, and tensioning each limb independently to remove any slack of tendon (right shoulder, lateral decubitus position, lateral portal for visualization, anterolateral portal as working portal).